Assessment of Stroke Volume Variation Perioperatively by Using Arterial Pressure with Cardiac Output

Objective To observe the sensitivity of stroke volume variation(SVV) for assessing volume change during induction period of general anesthesia. Methods Patients who underwent orthopaedic surgery under general anesthesia and mechanical ventilation were divided into two groups randomly. Patients in the group Ⅰwere subjected to progressive central hypovolemia and correction of hypovolemia sequentially; patients in the Group Ⅱ were exposed to hypervolemia alone. Each step was implemented after 5 minutes when the hemodynamics was stable. SVV and cardiac index(CI) were recorded, and Pearson's product-moment correlation was used to analyze correlation between SVV and CI. Results Forty patients were included in this study, 20 cases in each group. For group Ⅰ patients, SVV was increased significantly along with blood volume reduction, and changes in CI were negatively correlated with changes in SVV(r=-0.605, P<0.01); SVV decreased significantly along with correction of blood volume; changes in CI were negatively correlated with changes in SVV(r=-0.651, P<0.01). For group Ⅱ patients, along with blood volume increase, SVV did not change significantly; changes in CI revealed no significant correlation with changes in SVV(r=0.067, P>0.05). Conclusion SVV is a useful indicator for hypovolemia, but not for hypervolemia.

Usefulness of Monitoring Stroke Volume Variations for Fluid Management During Pediatric Living-Donor Liver Transplantation

Purpose: Central venous pressure (CVP) is considered to be unsuitable as preload parameter. Stroke volume variation (SVV) has recently been reported to be effective as a preload and fluid responsiveness parameter, and its usefulness for fluid management during living-donor liver transplantation (LDLT). However, use of SVV has not been reported in children. Our aim is to evaluate the use of SVV as a target parameter of circulating blood volume during pediatric LDLT. Methods: This retrospective study was conducted in 40 consecutive patients aged between 5 and 109 months who underwent elective LDLT. Twenty patients underwent LDLT without FloTrac? (C group) and the rest patients underwent LDLT with the FloTrac? monitoring (F group). As a fluid management target, CVP was maintained at 10 mmHg in the C group and SVV at 10% in the F group. We compared MAP and CVP at the times of the greatest decrease within 5 minutes after reperfusion. Results: MAP after reperfusion was significantly decreased in both groups (P < 0.01), with the magnitude of decrease significantly greater in the C group compared with the F group (P = 0.02). MAP before and after reperfusion did not significantly differ between the groups. After reperfusion, CVP was nearly the same in both groups, with that in the C group slightly decreased and nearly no change in the F group. SVV after reperfusion was significantly increased (P < 0.001). Conclusion: When used as a target parameter for fluid management during pediatric LDLT, hemodynamic changes was less when SVV was used as the parameter of circulating blood volume.

Assessment of Pericardium Volume by the Stroke Volume Variation in Patients with Off-Pump Cardiac Surgery

Objective: SVV is derived from the cardiopulmonary interaction, which is used to predict the responsiveness of cardiac preload guiding fluid therapy in patients under general anesthesia in non-opened chest surgery. From a clinical point of view, it is important to know how well SVV reflects preload and fluid responsiveness during cardiac surgery. This study was undertaken to assess the accuracy and reliability of SVV derived from the FloTrac/Vigileo system in monitoring changes in blood volume in patients undergoing off-pump coronary artery bypass grafting (OPCABG) under general anesthesia. Methods: After approval from the ethics committee and obtaining the permission of the patients, twenty-nine patients, ASA II-III and NYHA II-III, aged 44-7 yr, undergoing elective off-pump coronary artery bypass grafting, were randomly divided into 2 groups: the control group (group C, n = 8) and volume expansion group (group V, n = 21). After patients entered the operating room, veins were put in line, ECG, HR, SpO2, and PETCO2 were continuously monitored. Left radial arterial and right internal jugular vein catheters were inserted under local anesthesia. The FloTracTM/VigileoTM system was connected and MAP, CO, CI, SVV, SV, SVI, SVR, SVRI, CVP were continuously monitored. BIS values were kept at 45%-55.6% hydroxyethyl starch 130/0.4 sodium chloride solution 7 ml/kg was intravenously infused after completion of sternotomy and pericardiotomy at a rate of 0.25 ml/kg–1/min–1 in group V. MAP, HR, CVP, systemic vascular resistance (SVR), SVV, and stroke volume index (SVI) were determined 10 min before (T1) and after the infusion of finished (T2), and the change rate (ΔHR, ΔMAP, ΔCVP, ΔSVR, ΔSVV, ΔSVI) was calculated. Sodium chloride injection 3 ml/kg was infused in group C. Results: CVP, SVI, CO and CI were increased after volume expansion, SVRI and SVV significantly decreased in group V(P < 0.01), while MAP and HR were not changed. Changes in HR(r = –0.737, P and SVR(r = –0.480, P were significantly correlated to changes in SVI, but there was no correlation between ΔCVP, ΔMAP, ΔSVV and ΔSVI.

Anatomy of the Brachial Plexus:A Rare Variation in the Laboratory of Anatomy of Bamako(Mali)

The brachial plexus (BP), established by the lap twigs of the last four cervical nerves and the first thoracic nerve, assures the driving and sensory innervation of the thoracic member. We bring back a case of rare anatomical variation of the brachial plexus. It is a 34-year-old corpse dissected in the laboratory of anatomy of the Faculty of Medicine and Odontostomatology of Bamako in September 2017. The lap twig of the fourth cervical root (C4) participated in the constitution of the brachial plexus. The superior trunk was normally constituted. The average trunk was formed by the cervical roots C7 and C8 instead of only C7. And consequently the inferior trunk was constituted by the thoracic root T1. The posterior beam was only formed by the posterior branches of the superior and more average trunk. The medial beam was formed by all of the inferior trunk which did not give posterior branch for the formation of the posterior beam. The variations of the brachial plexus could entrain failures in the loco regional anesthesia of the brachial plexus.

Perioperative massive cerebral stroke in thoracic patients:Report of three cases

BACKGROUNDPerioperative stroke is a rare but devastating complication. The risk factors formassive cerebral stroke in surgical patients include older age, male sex, priorcerebrovascular disease, hypertension, renal failure, smoking, diabetes mellitus,and atrial fibrillation.CASE SUMMARYWe describe two cases of perioperative massive cerebral stroke following thoracicsurgery and one case following bronchoscopy. Neurologic symptoms, includingchanges in mental status and hemiplegia, occurred within 10 h after surgery in thethree patients. All three patients died after the surgery.CONCLUSIONPerioperative massive cerebral stroke may be more likely to occur in thoracicsurgical patients if there are pre-existing factors including previous stroke,hypotension, and hypoxemia. Sufficient pain control after surgery and timelyneurology consultation and management are helpful for the diagnosis and controlof stroke in high-risk patients.

下腔静脉变异度联合SVV指导下的目标导向液体治疗在腹腔镜肠癌根治术麻醉管理中的应用

目的 探讨下腔静脉变异度联合每搏量变异度(SVV)指导下的目标导向液体治疗在腹腔镜肠癌根治术患者麻醉管理中的应用效果。方法 选取2021年7月至2022年6月择期行腹腔镜下肠癌根治术患者60例,按照不同目标导向液体治疗分为常规补液组(对照组)和SVV组(观察组)各30例。比较两组术中液体出入量、不同时间点血流动力学和视神经鞘直径(ONSD)、术前及术后实验室指标水平[C反应蛋白(CRP)、下腔静脉变异度、纤维蛋白原(FIB)、血浆血栓素B2(TXB2)],术前及术后1、3 d认知功能。结果 观察组总入量、胶体量低于对照组(P<0.05),两组晶体量比较差异无统计学意义(P>0.05)。两组部分时间点血流动力学和ONSD差异有统计学意义(P<0.05)。术前和术后1 d实验室指标水平差异有统计学意义,且观察组CRP、FIB水平低于对照组,下腔静脉变异度高于对照组(P<0.05)。术前及术后3 d,两组认知功能差异无统计学意义(P>0.05),术后1 d观察组认知功能评分高于对照组(P<0.05)。结论 下腔静脉变异度联合SVV指导下的目标导向液体治疗应用于腹腔镜肠癌根治术患者麻醉管理中,能够优化术中液体管理,减少外科应激,维持患者内环境稳定,降低术后短期认知功能损害程度,于患者术后康复有益。

缺血性脑卒中介入治疗麻醉中应用盐酸右美托咪定的临床价值分析

目的 分析缺血性脑卒中介入治疗麻醉中应用盐酸右美托咪定的临床价值。方法 80例接受介入手术治疗的缺血性脑卒中患者,按照计算机表法分为对照组以及实验组,每组40例。两组采用相同的麻醉诱导方法 ,对照组采用间断推注顺阿曲库铵联合七氟烷吸入麻醉,实验组应用盐酸右美托咪定麻醉。比较两组不同时间生命体征、麻醉效果、不良反应发生情况。结果 麻醉后及手术后,实验组心率(84.25±7.16)、(82.32±6.28)次/min以及平均动脉压(92.24±3.58)、(90.17±5.24)mm Hg(1 mm Hg=0.133 kPa)均低于对照组的(96.48±6.88)、(86.81±5.77)次/min和(103.11±4.05)、(94.92±5.48)mm Hg,组间存在差异(P<0.05)。实验组麻醉效果总优良率为97.50%,与对照组的82.50%进行比较,实验组更高,组间存在差异(P<0.05)。实验组不良反应发生率2.50%明显低于对照组的20.00%,组间存在差异(P<0.05)。结论 缺血性脑卒中患者进行介入治疗麻醉时应用盐酸右美托咪定的麻醉效果显著,并且不良反应较少,值得在临床中推广应用。

麻醉方式对急性后循环脑卒中血管内治疗患者神经功能结局的影响

目的:比较急性后循环缺血性脑卒中患者在血管内治疗时选择清醒镇静和全身麻醉两种方式对患者神经功能结局的影响。方法:回顾性分析2017年1月至2022年12月在急性卒中质量评估与管理在线数据库(来源于CASE-Ⅱ研究,NCT04487340)登记的656例急性后循环脑卒中血管内治疗患者的临床资料,根据麻醉方式不同分为清醒镇静组(163例)和全身麻醉组(493例)。倾向性评分匹配后428例患者纳入分析,其中清醒镇静组(155例),全身麻醉组(273例)。比较两组手术方式、病因分型、血管再通情况、24 h出血转化、3个月改良Rankin量表(mRS)评分和3个月死亡的差异,采用二元logistic回归分析不同麻醉方式对神经功能结局等的影响。结果:倾向性评分匹配后,清醒镇静与全身麻醉患者除手术方式差异有统计学意义(P<0.01),两组病因分型、血管再通情况、出血转化、3个月mRS评分和3个月死亡差异均无统计学意义(均P>0.05)。二元logistic回归分析结果显示,清醒镇静与全身麻醉患者在血管内治疗后良好功能结局方面差异无统计学意义(OR=1.151,95%CI:0.751~1.765,P>0.05),在患者3个月mRS评分3分及以下、3个月mRS评分4分及以下、3个月死亡、血管再通良好和24 h出血转化方面差异也无统计学意义(均P>0.05)。结论:对于接受血管内治疗的后循环脑卒中患者,采用清醒镇静或全身麻醉对患者神经功能结局无明显影响。

连续无创血流动力学参数监测在脓毒症患者预后预测中的临床价值

目的探讨连续无创血流动力学参数监测在脓毒症患者预后预测中的临床价值。方法前瞻性选取2019年5月至2022年10月内江市第一人民医院收治的135例脓毒症患者,根据住院预后情况分为死亡组(n=32)和生存组(n=103)。于液体复苏前(T_(0))、液体复苏1 h(T_(1))、液体复苏2 h(T_(2))、液体复苏4 h(T_(3))时间点连续监测脓毒症患者无创血流动力学参数[心脏指数、心输出量、每搏输出量(SV)、每搏变异率(SVV)]变化,比较两组患者不同时间点的无创血流动力学参数变化;采用多因素Logistic回归模型分析影响脓毒症患者预后的因素;采用受试者操作特征(ROC)曲线分析心脏指数、心输出量、SV、SVV在脓毒症患者预后预测中的价值。结果脓毒症患者T_(1)、T_(2)、T_(3)时心脏指数、心输出量、SV、SVV均高于T_(0)时,差异均有统计学意义(P<0.05);T_(3)时心脏指数、心输出量、SV、SVV低于T_(2)时,差异均有统计学意义(P<0.05)。T_(1)、T_(2)、T_(3)时刻死亡组患者的心脏指数、心输出量、SV、SVV均明显低于生存组,差异均有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,T_(1)、T_(2)、T_(3)时心脏指数、心输出量、SV、SVV均是影响脓毒症患者预后的相关因素(P<0.05);ROC曲线显示,T_(3)时刻心脏指数、心输出量、SV、SVV联合预测预后的曲线下面积(AUC)值(0.884)最大。结论无创血流动力学监测指标心脏指数、心输出量、SV、SVV可有效预测脓毒症患者预后,且联合检测预测预后的价值更高。

Responsiveness of stroke volume variation and central venous pressure during acute normovolemic and hypervolemic hemodilution

Background Stroke volume variation （SW） is a robust indicator of fluid responsiveness during volume change. We compared the sensibility of SW by Vigileo/Flotrac to central venous pressure （CVP） when volume changes in patients undergoing intraoperative acute normovolemic hemodilution （ANH） and acute hypervolemic hemodilution （AHH）. Methods Forty patients were randomly divided into an ANH group （n=20） and an AHH group （n=20）. All patients received general anesthesia and were mechanically ventilated. Data were collected from 7 different time-points in the ANH group： baseline, after withdrawal of 5%, 10%, and 15% of the estimated blood volume （EBV） and after replacement with an equal volume of 6% hydroxyethyl starch 130/0.4 （HES） in 5% EBV increments to baseline. There were four time points in the AHH group： baseline, after 5%, 10%, and 15% expansion of the EBV with 6% HES. At each time-point, CVP, SW and other hemodynamic parameters measurements were obtained. Results After removal of 10% and 15% EBV, SVV significantly increased from 10.9±3.0 to 14.1±3.4 and 10.9±3.0 to16.0±3.3 （P 〈0.01）, and returned to a final value of 10.6±3.4 after volume replacement. The CVP value was unchanged after removal and replacement of 15% of the EBV. There were no significant changes in SW after 5%, 10% whereas there was a significant reduction after 15% （8.2±1.7） expansion of the EBV compared with baseline （9.9±1.8） （P=0.033）. However, there was a significant increase in CVP after10% （10.3±2.4）, 15% （11.3±2.2） expansion of the EBV compared with baseline （8.2±2.7） （P 〈0.01）. Conclusion SW is a more sensitive parameter for volume than CVP during hypovolemia, on the contrary CVP is more sensitive than SW during hypervolemia.

超声检测下腔静脉和锁骨下静脉内径变异在预测全身麻醉诱导后低血压中的价值

目的:分析超声检测下腔静脉(IVC)和锁骨下静脉(SCV)内径变异在预测全麻诱导后低血压(PIH)中的价值。方法:回顾性选取2021年5月—2023年5月在咸宁市第一人民医院行全麻手术的204例患者作为研究对象,根据是否发生PIH将其分为研究组(发生PIH,86例)和对照组(未发生PIH,118例)。对两组患者的基础资料、麻醉诱导前血压、麻醉诱导药物用量进行对比。比较IVC内径的最大值(IVCmax)和最小值(IVCmin)、SCV内径的最大值(SCVmax)和最小值(SCVmin),并计算IVC塌陷指数(IVCCI)和SCV塌陷指数(SCVCI)。采用受试者工作特征(ROC)曲线分析IVC、SCV内径及变异对全麻PIH的预测价值。结果:两组基础资料、麻醉诱导前血压指标和麻醉诱导药物用量比较,差异均无统计学意义(P>0.05)。研究组IVCmax、IVCmin、SCVmax、SCVmin水平均低于对照组,IVCCI、SCVCI水平均高于对照组,差异均有统计学意义(P<0.05)。受试者操作特征(ROC)曲线分析结果显示,麻醉诱导前IVCmax、IVCmin、SCVmax、SCVmin、IVCCI、SCVCI水平预测PIH的ROC曲线下面积(area under curve,AUC)分别为0.674、0.675、0.618、0.707、0.895、0.905,其中,SCVCI的AUC和cut-off值下的敏感度均为最高,分别为0.905、65.12%。结论:全麻PIH患者可表现为IVC和SCV内径缩小及IVCCI、SCVCI等内径变异指标的增高,采用血管超声技术检测上述变异指标可辅助预测PIH风险。

血流动力学监测仪指导目标导向液体治疗对妇科腹腔镜手术患者术后恶心呕吐的影响因素研究

目的:探讨LIDCOrapid型血流动力学监测仪指导目标导向液体治疗(GDFT)对妇科腹腔镜手术患者术后恶心呕吐(PONV)的影响因素。方法:选择2020年8月至2021年6月山东第二医科大学附属医院收治的90例全麻下行腹腔镜广泛性全子宫切除术患者,采用随机数表法将其分为观察组和对照组,每组45例。对照组根据尿量和平均动脉压(MAP)指导补液,观察组根据每搏量变异度(SVV)指导GDFT进行补液。观察患者进入手术室后10min(T0)、麻醉诱导后3 min(T1)、Terndelenburg体位后3 min(T2)、Terndelenburg体位后30 min(T3)、Terndelenburg体位后1 h(T4)和术毕(T5)时的MAP、心率(HR)、SVV、心指数(CI);以及术中液体出入量、术后胃肠功能恢复指标和住院时间。分析主要结局指标的PONV发生率,次要结局指标的术后0~6 h(T6)、6~12 h(T7)、12~24 h(T8)及24~48 h(T9)的PONV评分,以及术后进行止吐补偿治疗的人数。结果:观察组PONV发生率低于对照组,差异有统计学意义(x^(2)=6.40,P<0.05),术后T6和T7的PONV评分降低,差异有统计学意义(t=4.92、3.42,P<0.05)。观察组在T4时的HR和CI高于对照组,差异有统计学意义(t=0.73、0.64,P<0.05),而T3~T5时的SVV均高于对照组,差异有统计学意义(t=2.28、3.42、4.10,P<0.05);观察组术中晶体液输入量和总输液量减少,胶体液输入量增加,与对照组比较差异有统计学意义(t=15.10、12.36、8.19,P<0.05);观察组术后排气时间、排便时间及进食时间均早于对照组,差异有统计学意义(t=3.79、2.09、2.54,P<0.05)。两组住院时间比较差异无统计学意义(P>0.05)。结论:LIDCOrapid型血流动力学监测仪指导的GDFT可降低妇科腹腔镜广泛性子宫切除术PONV的发生率和术后12 h内PONV的严重程度。

不同体位及气腹压下脉搏灌注变异指数与每搏量变异度的相关性分析

目的探讨不同体位、气腹压下脉搏灌注变异指数(pleth variability index,PVI)与每搏量变异度(stroke volume variation,SVV)的相关性。方法选取2022年6—12月内蒙古自治区人民医院择期行腹腔镜右半结肠癌根治术的患者60例,全麻后依次在水平位(T1)、Trendelenburg位(T2)、Trendelenburg左倾45°位(T3)3种体位下监测患者HR、MAP、PVI及SVV的变化,并分析不同体位下PVI与SVV的相关性。手术前根据不同气腹压将患者分为A组(10 mmHg)、B组(12 mmHg)和C组(14 mmHg)(1 mmHg=0.133 kPa),每组20例,监测3组不同体位下HR、MAP、PVI及SVV的变化,并分析不同气腹压下PVI与SVV的相关性。结果60例患者中男32例、女28例,平均年龄(53.1±7.7)岁。气腹前,与T1时相比,T2、T3时的HR较低,差异有统计学意义(P<0.05);3种体位下PVI与SVV均存在线性正相关(P<0.05)。气腹后3种体位下,与A组相比,B组、C组的MAP、PVI、SVV均较高;与B组相比,C组HR较低、MAP较高,差异均有统计学意义(P<0.05)。气腹后3种体位下,A组PVI与SVV均呈线性正相关(P<0.05)。结论无气腹状态下,不同体位下PVI与SVV均呈线性正相关。低气腹压(10 mmHg)下,不同体位时PVI与SVV呈线性正相关。体位虽不影响PVI与SVV的正相关性,但超过10 mmHg的气腹压会影响二者的正相关性。

脉压变异度和每搏量变异度用于神经外科手术容量监测相关性的研究

目的探讨Philips IntelliVue MP70监护仪所测脉压变异度(PPV)和FloTrac/Vigileo所测每搏量变异度(SVV)用于神经外科手术容量监测的相关性。方法选择神经外科择期开颅手术患者40例,记录气管插管后机械通气状态下血流动力学平稳后潮气量为8 ml/kg时的平均动脉压(MAP)、心率(HR)、心指数(CI),每搏量指数(SVI),SVV,PPV;将潮气量调为10 ml/kg通气1 min后记录以上数据。然后潮气量调为8 ml/kg直至手术结束。记录气管插管后160 s(T1),320 s(T2),800 s(T3),1 600 s(T4)和3 200 s(T5)时的SVV和PPV值并做相关分析。结果在输液条件不变的情况下,潮气量由8 ml/kg变为10 ml/kg时,SVV和PPV均上升(P<0.01);增加值为△(2.4±1.7)vs.△(2.9±2.1),增加值之间具有显著相关性(r=0.826,P<0.01)。机械通气(8 ml/kg)后各时点的PPV和SVV数值具有高度相关性,r值分别为T1:r=0.961,P<0.01;T2:r=0.953,P<0.01;T3:r=0.956,P<0.01;T4:r=0.926,P<0.01;T5:r=0.902,P<0.01。结论Philips IntelliVue MP70监护仪所测PPV和FloTrac/Vigileo所测SVV用于神经外科手术的容量监测具有高度相关性,均可用于神经外科手术的目标导向容量管理。

热连轧粗轧短行程控制全程优化

从生产现场的实际情况出发 ,结合现场工艺和实际数据 ,利用数学模型对带钢端部的宽度变化进行了模拟计算 ,并进一步利用遗传算法对粗轧短行程控制进行全程优化。结果表明 ,利用遗传算法可明显优化短行程控制参数 ,提高带钢端部宽度的控制精度 ,减少切头切尾损失 。

中心静脉压联合每搏心输出量对全麻患者容量反应性的预测价值

目的探讨中心静脉压(CVP)联合每搏心输出量(SV)对全麻患者容量反应性的预测价值。方法选择ASA Ⅰ~Ⅱ级胃肠外科肿瘤择期大手术患者80例,麻醉诱导后以6%羟乙基淀粉进行容量负荷,每次剂量3 ml/kg,连续3次。分别于麻醉前、每次容量负荷之前,应用Flo Trac/Vigileo监测SV和每搏心输出量变异(SVV),同时测量CVP值。容量负荷后患者的SV增加≥10%定义为容量负荷有反应性,此患者称作"有反应者";SV增加<10%的患者称作"无反应者"。结果对容量负荷无反应者的CVP值高于有反应者(7.2 mm Hg vs 5.6 mm Hg,P<0.01),无反应者中CVP值不变者对再次容量负荷有反应性的预测概率为48%;而CVP值升高者对容量负荷有反应性的预测概率为9%(P<0.01)。对于容量负荷反应性的判断,SV和SVV两种标准具有中等程度的一致性(Cohen's kappa系数0.28)。结论对于容量无反应的患者CVP可以作为辅助指标指导容量负荷。SVV与SV对于预测容量反应性存在一致性,但一致性程度不够理想。

潜在类别分析在缺血性中风病患者证候数据中的应用

目的探讨观测结果为证候数据时潜在类别分析在样品聚类中的应用,及不同首发证候缺血性中风病患者各证候随时间的变化规律。方法采用潜在类别分析将1023例缺血性中风病住院患者按首发证候进行聚类,计算各组患者各时点各证候的频率,并绘制线图。结果根据潜在类别分析模型的拟合统计量及似然比检验得出4个潜在类别的模型是首选模型,缺血性中风病住院患者可聚为4个亚组,"内湿+血瘀"组98人,"痰+血瘀"组485人,"血瘀"组266人,"多种证候"组160人。经潜在类别分析聚成的4组患者,各证候的发生率及随时间的变化趋势不尽相同。结论潜在类别分析可用于观测结果为证候数据的样品聚类,聚类后各组各证候随时间的变化规律不同,对更深刻地揭示缺血性中风病的病机本质,更准确地指导临床中医药干预有实际意义。

血管内治疗的急性缺血性脑卒中患者合并肺部感染的相关危险因素分析

目的观察接受血管内治疗的急性缺血性脑卒中患者合并肺部感染的相关危险因素。方法回顾性分析2016年1月~2018年6月南宁市第二人民医院神经内科接受血管内治疗的急性缺血性脑卒中患者124例,根据是否并发肺部感染分为感染组48例,非感染组76例。分析2组一般情况和可能影响发生肺部感染的相关因素。疾病的严重程度采用美国国立卫生研究院卒中量表(NIHSS)评分和格拉斯哥昏迷评分(GCS)。采用logistic回归分析急性缺血性脑卒中患者发生肺部感染的独立危险因素。结果感染组年龄≥70岁、术前NIHSS评分>15分、术前GCS≤8分、糖尿病、慢性肺病、后循环病变、机械取栓和抽吸、全身麻醉、术后持续镇静>1 d、气管插管>1 d及呼吸机辅助通气>1d比例明显高于非感染组,局麻加深度镇静比例明显低于非感染组,差异有统计学意义(P<0.05,P<0.01)。多因素logistic回归显示,术前NIHSS评分>15分(OR=2.558,95%CI:1.741~2.563,P=0.003)、术前GCS≤8分(OR=4.358,95%CI:1.568~5.374,P=0.001)、后循环病变(OR=3.589,95%CI:0.328~3.251,P=0.005)、全身麻醉(OR=1.025,95%CI:1.159~2.664,P=0.041)和术后持续镇静>1 d(OR=3.254,95%CI:2.682~3.267,P=0.028)是血管内治疗的急性缺血性脑卒中并发肺部感染的独立危险因素。结论病情严重程度、病变部位、意识障碍和慢性肺病是导致急性期血管内介入患者合并肺部感染的危险因素。

俯卧位呼吸末正压对每搏量变异度、脉搏压变异度和脉搏灌注变异指数预测容量准确性及阈值的影响

目的观察俯卧位应用不同呼气末正压条件下对每搏量变异度、脉搏压变异度及脉搏灌注变异指数预测容量状态的准确性及诊断阈值的影响。方法选择在全麻下俯卧位行颈椎或腰椎手术患者60例,全麻后连续监测每搏量变异度(SVV)、脉搏压变异度(PPV)、脉搏灌注变异指数(PVI)等血流动力学指标,在俯卧位体位下分别加以0、5、10、15 mm Hg的呼气末正压(PEEP),记录每个PEEP时点的各血流动力学指标数值,后以7 ml/kg进行补液试验后,再分别加以0、5、10、15 mm Hg的PEEP值后记录输液后各血流动力学指标数值。然后以输液前后每搏量变异指数的差值(ΔSVI)将患者分为两组,即有反应组(ΔSVI≥15%)和无反应组(ΔSVI<15%)组,分别绘制SVV、PPV和PVI判断扩容效应的受试者工作特征性(ROC)曲线,确定俯卧位时在不同PEEP条件下对SVV、PPV和PVI预测容量状况的准确性、诊断阈值及其相关性。结果与平卧位相比较,俯卧位条件下SVV、PPV、PVI均增大(P<0.05),平均动脉压降低(P<0.05),心率、每搏量、每搏量指数、心输出量、心指数差异无统计学意义(P>0.05)。俯卧位时,在PEEP=0、5、10、15 mm Hg条件下,SVV判断扩容有效的ROC曲线下面积分别为0.864、0.759、0.718、0.521,PPV判断扩容有效的ROC曲线下面积分别为0.873、0.792、0.705、0.505,PVI判断扩容有效的ROC曲线下面积分别为0.851、0.765、0.709、0.512。当PEEP=0 mm Hg时,SVV、PPV、PVI诊断阈值分别为10.5、11.5、13.5;当PEEP=5 mm Hg时,SVV、PPV、PVI诊断阈值分别为11.5、13.5、14.5;当PEEP=10 mm Hg时,SVV、PPV、PVI诊断阈值分别为13.5、14.5、16.5。俯卧位时在不同PEEP条件下SVV、PPV、PVI变化分别与PEEP值变化呈正相关(r分别为0.424、0.561、0.553,P<0.01)。结论 SVV、PPV和PVI在PEEP≤10 mm Hg时可以准确预测俯卧位时应用全麻机械通气患者的容量状况,三者预测容量状况的准确性相似,诊断阈值随PEEP值增大而增大,诊断的准确性随PEEP值增大而下降;在PEEP=15 mm Hg时,SVV、PPV和PVI不能准确预测俯卧位时应用全麻机械通气患者的容量状况。